We’ve always argued that no one should go to jail for possession of marijuana and I agree that it makes sense for the federal government to step out of the way of states that want to try another path. The NY Times editorial board comes out in favor of marijuana legalization.
I’m ambivalent about full legalization and worry about the effects of unleashing capitalism on marijuana. (This is where people point to alcohol and I respond, “Yeah, look at alcohol–it’s a celebrated drug in the culture with huge public health challenges and a powerful lobby.)
In the midst of all this skepticism about the possibility of an effective prohibition policy, a couple of sentences lept out at me.
There are legitimate concerns about marijuana on the development of adolescent brains. For that reason, we advocate the prohibition of sales to people under 21.
Seems like there’s a little dissonance there, no? (On second thought, I’m convinced that an absence of dissonance is a sure sign of someone who is ideological or isn’t very serious about the matter. I guess the key is to be aware of your dissonance.)
In any case, everyone’s a critic of the status quo. The real question is how to implement policy change, whether it’s full legalization or some option short of that. This will separate the critics from the more serious thinkers on the issue.
I’ve said it many times here. There is no such thing as a problem-free drug policy. The reality is that we have to choose which problems we’re willing to live with and which problems we can’t tolerate and then craft a policy around those values.
We seem to have decided that we’re willing to live with marijuana use by adults but we’re not willing to live with incarcerating large numbers of people for using it and we don’t want young people using it heavily. There are a lot of policy options to fit those criteria.
This week’s Throwback Sunday is a post about a study on the Transtheoretical Stages of Change (TSOC). It’s relevant due to the ongoing and recent media love for Motivational Interviewing (MI), which is fairly closely tied to the TSOC. (This is disputed, but the motivational interviewing website as 12 pages of search results for “stages of change”.)
Just to be clear, Dawn Farm likes MI. We train staff in MI. We believe it’s a useful tool. However, we also believe it’s often oversold as a treatment for addiction. It may be helpful as a stand-alone intervention for people with low-severity substance use problems. For addiction, it can be very helpful to engage people into other treatments more appropriate for high-severity problems.
Another study finding that the client’s stage of change is a poor predictor of outcomes:
Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.
There has been high profile criticism that the rush to embrace the stages of change has outpaced the evidence. The question isn’t whether the stages of change have any utility. The question is what are they useful for? Patient/family eduction, counselor education, conceptualizing interventions, matching treatments, etc.
The stages of change have undoubtedly changed the field for the better, but there are a lot of weak points that have not been adequately explained–failure to recognize the instability of motivation; disagreements about how to determine the client’s stage of change; failure to account for stable, unplanned change; failure to explain for stable, initially coerced change. I’ve been especially concerned about practitioners relying on the stages of change for treatment placement and the inevitable post hoc deconstructions of treatment “failures” that blame the client’s motivation and then conclude that we wasted money treating them (and suggest that better assessment would have led to the conclusion that the client wasn’t motivated and a better referral).
Robert West, the editor of Addiction, has offered a new model for understanding change, he has called the PRIME theory.
I’m not a fan of either of these high profile addiction experts, but Stanton Peele’s recounting of his meeting with Gabor Maté illuminates a lot about both men and their approach to addiction. It also helps in understanding the conceptual boundaries of harm reduction, at least as Peele sees them. The boundaries are more rigid than I would have imagined.
Seeking common ground with Gabor, I noted his work with psychedelics as a chance to teach people how to manage drug experiences. But he told me that teaching people competency in drug use is the last thing on his mind. I emailed him in March this year:
I DO like this title—Substance Use Competency. It is interesting to play that idea out—including dealing with people’s traumas (without allowing them to grow to life-overcoming proportions) while also actually teaching them to manage substance use (as you are doing in Mexico). Perhaps we can combine around this.
Gabor responded by rapping my knuckles:
We are not teaching substance use competency with this process. The goal and process is to help people shed the physical and psychological patterns of old trauma, so that they are no longer trapped in the past. If successful, substance use is no longer an imperative. [My emphases.]
The last thing in the world Maté wants people to do is to take drugs as a normal part of life experience. In this way, he is no more a harm reductionist than Nancy Reagan.
Hmmm. Like I said, I’m no fan of Maté, but the goal of eliminating substance use as an imperative puts one in the same category as Nancy Reagan? Count me in that club.
In that Points interview, Bill White is asked about the treatment provider that he would choose for a loved one.
I receive calls every day from people asking variations of these questions. There isn’t a universally “best program.” What we are looking for is the best match between the characteristics of a particular person at a particular point in time and the characteristics of a treatment setting at that same point in time. What could be the best choice for one person would not necessarily be a good choice for another, and a good match today might not be so a year from now—because both individual/family needs and organizational capabilities evolve dynamically. But those best matches do seem to share some common characteristics: accessibility; affordability; organizational and workforce stability; individualized, evidence-based, and family-focused care; a recovery-infused service milieu; effective linkage to recovery community resources; and sustained support for both the individual and the family. What also matters as much as the treatment approach and the treatment institution is the primarily clinician who will be providing that treatment. Recovery outcomes vary widely from counselor to counselor.
Interesting to see affordability on that list. Again, I’m grateful to be part of a place that resembles this description.
From Humans of New York:
“She was filled with regret before she died. She felt like she’d failed us as a mother tremendously.”
“Did she say something to you about it?”
“She never said anything, so I don’t have any tangible proof that she had regrets. But she had a very bad substance abuse problem. And I know she always wanted to be a good mother. So I separate my mom from her disease. I always imagine that my mom and an alcoholic were living in the same body. And I know that my mom loved us. And that she hated the alcoholic.”
Points has an interview with Bill White. He makes several points that his followers will be very familiar with, but I don’t remember him putting it together so concisely. I’ve also heard him discuss recovery capital and acute care models, but never heard him frame the acute care model as working well for low to moderate severity with high recovery capital. It puts a different frame on the the persistence of the model and cultural barriers to changing it.
. . . the cultural fate of addiction treatment may well be dictated by a more fundamental flaw in the very design of addiction treatment and the field’s capacity or incapacity to respond to that design flaw. Modern addiction treatment emerged as an acute care model of intervention focused on biopsychosocial stabilization. This model can work quite well for people with low to moderate addiction severity and substantial recovery capital, but it is horribly ill-suited for those entering treatment with high problem severity, chronicity, and complexity and low recovery capital. With the majority of people currently entering specialized addiction treatment with the latter profile, the acute care model’s weaknesses are revealed through data reporting limited treatment attraction and access, weak engagement, narrow service menus, ever-briefer service durations, weak linkages to indigenous recovery support services, the marked absence of sustained post-treatment recovery checkups, and the resulting high rates of post-treatment addiction recurrence and treatment readmission. Addiction treatment was developed in part to stop the revolving doors of hospital emergency rooms, jails and prisons. For far too many, it has become its own revolving door. Slaying the Dragon documents these weaknesses and current efforts to extend the design of addiction treatment toward models of sustained recovery management nested within larger recovery-oriented systems of care—with the “system” being the mobilization of recovery supports within the larger community.
I’m grateful to work in a program that provides long term care and support.
“If they overdose and kill themselves, it just removes them from the gene pool.”
State Senator Rob Schaaf, a family physician who argues that allowing the government to keep prescription records violates personal privacy. (Source: NYT; hat tip: @DavidJuurlink)
Keith Humphreys imagines the reactions of various stakeholders to this graph showing marijuana consumption Colorado.
- He imagines public health workers expressing concern about the bottom two bars and trying to promote policies that will reduce the amount these heavy users consume.
- Next, he imagines a corporate board room voicing interest in attracting users in the bottom two bars to their brand and finding ways to retain them.
- Finally, he puts us in the legislature, which is torn between improving public health and the tax revenue these heavy users provide.
He adds that this illustrates that there is no such thing as value-free policy.
A study of opioid-related deaths in Ontario was recently published. There were some really stunning findings.
First, over 20 years, the opioid-related death rate increased by 242%.
During the 20-year study period, we identified 5935 people whose deaths were opioid-related in Ontario. The median age at death was 42 years (interquartile range 34–50 years), 64.4% (n = 3822) of decedents were men and 90.0% (n = 5340) lived in an urban neighborhood. During the study period, rates of opioid-related death increased dramatically, rising 242% from 12.2 deaths per million in 1991 (127 deaths annually) to 41.6 deaths per million in 2010 (550 deaths annually; Figure 1).
Second, young adults have been hit especially hard. [emphasis mine]
The highest absolute increase occurred among individuals aged 25–34 years, in whom the proportion of deaths related to opioids increased from 3.3% in 1992 to 12.1% in 2010.
. . .
The finding that one in eight deaths among young adults were attributable to opioids underlines the urgent need for a change in perception regarding the safety of these medications.
When we see these kinds of statistics in the US, we’re left to wonder the role that poor treatment access played.
We conducted a serial cross-sectional study of all opioid-related deaths in Ontario, Canada between 1 January 1991 and 31 December 2010. Ontario is Canada’s largest province, with more than 13.2 million residents in 2010, all of whom have access to publicly funded health insurance for physician and hospital services.
I don’t know much about the kind of treatment that’s been available to Ontario addicts. It’d be interesting to learn more about that.
This week’s Throwback Sunday is Bill White’s description of radical recovery.
For MLK day, here’s an article by Bill White on “radical recovery.” He describes a convergence of social activism and addiction recovery.
The article offers a model that goes well beyond the the interests of recovering people themselves and encourages advocacy in larger community contexts:
A radical recovery movement is now rising in America. That movement is flowing from the realization that addiction and its progeny of problems are visible everywhere, while recovery from addiction lies hidden. It is rising in the recognition that the stigma attached to AOD problems has increased in recent decades and has fueled the demedicalization and recriminalization of these problems. What started out as “zero tolerance” for drugs rapidly evolved into zero tolerance for people with AOD problems. It is in this regressive climate that a style of recovery is emerging that is radical in its scope (focus on environmental as well as personal transformation), radical in its inclusiveness (celebration of multiple pathways and styles of recovery), and radical in its synthesis of social responsibility and personal accountability. People in recovery are looking beyond their own addiction and recovery experiences to the broader social conditions within which AOD problems arise and are sustained. A radicalized vanguard of people in recovery is using personal transformation as a fulcrum for social change. They are living Gandhi’s challenge to become the change they wish to see in the world. Those who were once part of the problem are becoming part of the solution.